VATI RN Maternal Newborn Assessment:Questions and Answers
A charge nurse is discussing care of clients who are in labor with a newly licensed nurse. Which of the following
actions should the charge nurse include in the teaching regarding situations requiring an amniotomy? -
ansPlacing a fetal scalp electrode.
A charge nurse is discussing syphilis with a newly licensed nurse. Which of the following statements should the
charge nurse make? - ansA chancre lesion appears within 90 day after infection during the primary stage.
A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum
hemorrhagic shock. Which of the following statements should the charge nurse make? - ansThe most accurate
indication of organ perfusion is a clients urine output.
A charge nurse is teaching a newly licensed nurse about substance use disorders during pregnancy. Which of
the following statements by the newly licensed nurse indicates an understanding of the teaching? -
ansEncourage client who are prescribed methadone to breastfeed.
A client who is in active labor is admitted to a labor and delivery unit and reports, "My water just broke and my
baby is breech." Which of the following actions should the nurse take first? - ansCheck fetal heart tones.
A nurse is admitting a client who is at 39wks of gestation and in active labor. The client reports being positive
for group B streptococcus (GBS) when screened at 36wks of gestation. Which of the following actions should
the nurse expect to take? - ansAdminister IV antibiotic prophylaxis.
A nurse is assessing a 1-hr-old newborn. Which of the following findings should the nurse report to the
provider? - ansGeneralized petechiae
A nurse is assessing a client who delivered a 4.5kg (10lbs) newborn 2hrs ago. Identify the level in the abdomen
a nurse should expect to find the client's uterus when assessing the fundus. - ansC is correct.
-Immediately after birth, the fundus should be firm, midline with the umbilicus, and approximately 2cm below
the level of the umbilicus. At 12hrs postpartum the nurse should palpate the fundus at 1cm (0.4in) above the
umbilicus. Every 24hrs the fundus should descend approximately 1-2cm (0.4-0.8in) It should be halfway
between the symphysis pubis and the umbilicus by 6 days postpartum.
, A nurse is assessing a client who gave birth 4hrs ago and is receiving 2 units packed RBCs due to a postpartum
hemorrhage. Which of the following findings is the best indication of adequate perfusion and oxygenation? -
ansUrinary output.
A nurse is assessing a client who has genital herpes. Which of the following findings should the nurse expect? -
ansUlcerated lesions on the labia.
A nurse is assessing a client who has just undergone a cesarean birth and was given epidural morphine for
postpartum pain relief 1hr ago. The nurse notes that the clients respiratory rate is 10/min. Which of the
following actions should the nurse take first? - ansAdminister oxygen by nonrebreather face mask.
A nurse is assessing a client who has placenta previa and is receiving fetal monitoring. Which of the following
clinical findings should the nurse expect? - ansPainless vaginal bleeding.
A nurse is assessing a client who has preeclampsia and received a dose a calcium gluconate to treat magnesium
sulfate toxicity. Which of the following findings should the nurse identify as an indication that calcium
gluconate was effective? - ansRespiratory rate 12/min
A nurse is assessing a client who is 2hr postpartum and has saturated a perineal pad in 15min. The clients skin
is cool and clammy to touch. Which of the following actions should the nurse take first? - ansFirmly massage
the fundus.
A nurse is assessing a client who is 6hrs postpartum, tachycardia, and has cool skin. The client reports that they
have been bleeding excessively. Which of the following actions should the nurse take? - ansInitiate and infusion
of oxytocin.
A nurse is assessing a client who is at 32wks of gestation. Which of the following findings is an indication of a
potential prenatal complication? - ansEpigastric pain.
A nurse is assessing a client who is at 33wks of gestation. Which of the following findings should the nurse
report to the provider? - ansEpigastric pain.
A charge nurse is discussing care of clients who are in labor with a newly licensed nurse. Which of the following
actions should the charge nurse include in the teaching regarding situations requiring an amniotomy? -
ansPlacing a fetal scalp electrode.
A charge nurse is discussing syphilis with a newly licensed nurse. Which of the following statements should the
charge nurse make? - ansA chancre lesion appears within 90 day after infection during the primary stage.
A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum
hemorrhagic shock. Which of the following statements should the charge nurse make? - ansThe most accurate
indication of organ perfusion is a clients urine output.
A charge nurse is teaching a newly licensed nurse about substance use disorders during pregnancy. Which of
the following statements by the newly licensed nurse indicates an understanding of the teaching? -
ansEncourage client who are prescribed methadone to breastfeed.
A client who is in active labor is admitted to a labor and delivery unit and reports, "My water just broke and my
baby is breech." Which of the following actions should the nurse take first? - ansCheck fetal heart tones.
A nurse is admitting a client who is at 39wks of gestation and in active labor. The client reports being positive
for group B streptococcus (GBS) when screened at 36wks of gestation. Which of the following actions should
the nurse expect to take? - ansAdminister IV antibiotic prophylaxis.
A nurse is assessing a 1-hr-old newborn. Which of the following findings should the nurse report to the
provider? - ansGeneralized petechiae
A nurse is assessing a client who delivered a 4.5kg (10lbs) newborn 2hrs ago. Identify the level in the abdomen
a nurse should expect to find the client's uterus when assessing the fundus. - ansC is correct.
-Immediately after birth, the fundus should be firm, midline with the umbilicus, and approximately 2cm below
the level of the umbilicus. At 12hrs postpartum the nurse should palpate the fundus at 1cm (0.4in) above the
umbilicus. Every 24hrs the fundus should descend approximately 1-2cm (0.4-0.8in) It should be halfway
between the symphysis pubis and the umbilicus by 6 days postpartum.
, A nurse is assessing a client who gave birth 4hrs ago and is receiving 2 units packed RBCs due to a postpartum
hemorrhage. Which of the following findings is the best indication of adequate perfusion and oxygenation? -
ansUrinary output.
A nurse is assessing a client who has genital herpes. Which of the following findings should the nurse expect? -
ansUlcerated lesions on the labia.
A nurse is assessing a client who has just undergone a cesarean birth and was given epidural morphine for
postpartum pain relief 1hr ago. The nurse notes that the clients respiratory rate is 10/min. Which of the
following actions should the nurse take first? - ansAdminister oxygen by nonrebreather face mask.
A nurse is assessing a client who has placenta previa and is receiving fetal monitoring. Which of the following
clinical findings should the nurse expect? - ansPainless vaginal bleeding.
A nurse is assessing a client who has preeclampsia and received a dose a calcium gluconate to treat magnesium
sulfate toxicity. Which of the following findings should the nurse identify as an indication that calcium
gluconate was effective? - ansRespiratory rate 12/min
A nurse is assessing a client who is 2hr postpartum and has saturated a perineal pad in 15min. The clients skin
is cool and clammy to touch. Which of the following actions should the nurse take first? - ansFirmly massage
the fundus.
A nurse is assessing a client who is 6hrs postpartum, tachycardia, and has cool skin. The client reports that they
have been bleeding excessively. Which of the following actions should the nurse take? - ansInitiate and infusion
of oxytocin.
A nurse is assessing a client who is at 32wks of gestation. Which of the following findings is an indication of a
potential prenatal complication? - ansEpigastric pain.
A nurse is assessing a client who is at 33wks of gestation. Which of the following findings should the nurse
report to the provider? - ansEpigastric pain.
